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EFS Transportation Services, Inc.
2525 Horizon Lake Drive, Suite 120
Memphis , TN 38133

 
Direct Bill Authorization  

Trucking Company Information
Account Number    
Company Name    
Contact Person    
Phone Number    
Fax Number    
P O Box    
Address    
City, State & Zip    

Truck Stop Information for Chains & Independent Stops
EFS TS Number    
Truck Stop Name    
Contact Person    
Phone Number    
 Chain Information
Includes all chain stops in direct bill   Yes   No    
If no, please attach list of direct bill stops with TS #'s  
Data Capture Fee Pick-Up Yes   No    

Upon receipt of a completed Direct Bill Authorization form, EFS Transportation Services will process the form and will begin treating the indicated stop(s) as Direct Bill for the named carrier. This means that EFS will merely capture the data and authorize the transactions, but the trucking company will settle with the truck stop(s) directly. EFS Transportation Services will no longer pay you for this company's transactions. By signing the Authorized Signature line, you are authorizing direct bill for your truck stop(s).

Authorized Signature Date

Upon completion email or fax to:

lisa.losby@efsts.com
Fax 813-891-0561

Question call 866-841-9315, ext. 18040